JANUARY

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JAPAN Organization of the Health System in Japan Legal Frameworks Medical Care Act, Health Insurance Act, National Health Insurance Act, and other relevant acts National Government The Cabinet Minister of Finance Minister of Health, Welfare and Labour Social Security Council Health Science Council Central Social Insurance Medical Council General health care policies Public health policies Payment rules (fee schedule) Japan Council for Quality Health care Pharmaceutical and Medical Devices Agency Payer representatives Experts Provider representatives Establishment of Regulations Funds for developing health care delivery Prefectures Health Care Council Planning and developing health care delivery Municipalities Also, serving as statutory health insurers Implementation of Regulations Hospitals Clinics Institutional long-term care providers Home care providers Japan Fair Trade Commission Implementation of fair competition policy on providers National Insurance Bodies Checking invoices from providers Notes: This chart illustrates a very simplified structure of the complex health care governance in Japan. Source: R. Matsuda, College of Social Sciences, Ritsumeikan University, 2015. What is being done to promote delivery system integration and care coordination? The national government prioritizes the general coordination of care, including coordination in mental health care, and has introduced financial incentives for hospitals and clinics, particularly in cancer, stroke, cardiac, and palliative care. Hospitals admitting stroke victims or patients with hip fractures can receive additional fees if they use post-discharge protocols and have contracts with clinic physicians to provide effective follow-up after discharge, for which those physicians also receive additional fees. The government also provides subsidies to leading providers in the community to facilitate care coordination. There are more than 4,000 “community comprehensive support centers” to coordinate services, particularly for those with long-term conditions. Funded by LTCI, they employ care managers, social workers, and long-term care support specialists. No pooled funding of the PHIS and LTCI exists. Regional and large-city governments are required to establish councils to promote integration of care and support for patients with 306 designated long-term diseases. What is the status of electronic health records? Electronic health record networks have been developed only as experiments in selected areas. Interoperability between providers has not been generally established. Currently, experiments are under way to make personal health information available to patients and providers via cloud computing. The Social Security and Tax Number 112 The Commonwealth Fund
JAPAN System (SSTNS), a system of unique identifiers, will begin in 2016. It will be used for social security from its inception, and for health services, possibly including medical records, starting in 2018. How are costs contained? Price regulation for all services under the PHIS is a critical cost-containment mechanism (Ikegami and Anderson, 2012). The fee schedule is revised every two years by the government, following informal stakeholder negotiations, and is based on the estimated overall rate of change in public health care expenditures and expenditures in different health care sectors. For medical, dental, and pharmacy services, the Central Social Insurance Medical Council revises fees on an item-by-item basis in order to meet overall spending targets set by the cabinet. Highly profitable categories see larger reductions. The revisions of prices of pharmaceuticals and devices are determined based on a market survey of actual current prices (which are often less than the listed prices). Drug prices can be revised downward for new drugs selling in greater volume than expected and for brand-name drugs when generic equivalents hit the market. Prices of medical devices in other countries are also considered in the revision. Negotiations between stakeholders take place only for the purpose of revising the fee schedule and the rule for deciding pharmaceutical prices. Whether cost-sharing and the existing competition between providers contain costs is unclear. The number of hospital beds is regulated by prefectures in accordance with national guidelines. The national medical student capacity, which is increasing since 2007 owing to physician shortages, is also regulated by the government. The government’s Cost-Containment Plan for Health Care is intended to promote healthy behavior, shorten hospital stays through care coordination and home care development, and increase generic substitution. Each prefecture makes cost-control plans in accordance with the plan. Both financial incentives in the fee schedule and other incentives, including education and training, are used. Peer review committees in each prefecture also monitor claims and may deny payment for services deemed inappropriate. Currently, some pharmaceuticals whose medical effectiveness is considered uncertain are not covered by the PHIS. A trial cost-effectiveness evaluation for coverage of selected pharmaceuticals and medical devices is scheduled for fiscal year 2016. What major innovations and reforms have been introduced? Community-based health insurance plans in the PHIS, operated by municipalities, usually insure residents who are sicker and less well-off than those covered by employment-based insurance plans. The plans vary significantly in the number they insure, from fewer than 100 to more than half a million. To mitigate financial risk in small plans, the national government has gradually expanded cross-subsidies between community-based plans while keeping its and local governments’ subsidies. With increasing financial pressures and the development of region-based governance, plans are being restructured under the 2015 Health Care Reform Act: from 2018, regions will take overall administrative responsibility for community-based plans and work together with municipalities, which will still be insurers of their residents, to set premium rates and to collect premiums. Meanwhile, subsidies from the national government to the regions are to be slightly increased to help plans, and those with low incomes, with excessive financial burdens. A plan to strengthen the financial incentive for patients to use family physicians is intended to decrease demand on hospital outpatient departments. Although hospitals with 200 beds or more are currently allowed to charge additional fees to patients who have no referral for outpatient consultations, fewer than half of such hospitals have opted for this extra charge. Under the Health Care Reform Act of 2015, highly specialized large-scale hospitals with 500 beds or more will have an obligation to promote care coordination between providers in the community, as well as to charge additional fees to such patients. International Profiles of Health Care Systems, 2015 113
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JANUARY 2016 2015 International Pro
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2015 International Profiles of Heal
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Table 1. Health Care System Financi
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Table 3. Selected Health System Per
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The Australian Health Care System,
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AUSTRALIA low-income adults, childr
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AUSTRALIA In 2013, the federal gove
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What is being done to reduce dispar
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References AUSTRALIA Australian Bur
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CANADA What is covered? Services: T
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CANADA funding to 145 not-for-profi
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CANADA Organization of the Health S
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CANADA provides recommendations to
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CANADA Health Council of Canada (20
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CHINA Private health insurance: Com
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CHINA is not substantially more exp
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CHINA Organization of the Health Sy
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CHINA References Chen, X. (2014).
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DENMARK In addition, nearly 1.5 mil
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DENMARK Social psychiatry and care
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DENMARK Quality data for a number o
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DENMARK portion is small, it makes
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48
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ENGLAND immunization, and vaccinati
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ENGLAND Hospitals: Publicly owned h
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ENGLAND Organization of the Health
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ENGLAND How are costs contained? Ra
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ENGLAND Organisation for Economic C
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FRANCE VHI finances 13.8 percent of
Page 62 and 63: FRANCE The average income of primar
Page 64 and 65: FRANCE What are the key entities fo
Page 66 and 67: FRANCE inequities in prevention rel
Page 68 and 69: FRANCE Nolte, E., C. Knai, and M. M
Page 70 and 71: GERMANY There were 42 substitutive
Page 72 and 73: GERMANY The 16 state governments de
Page 74 and 75: GERMANY management system, by the s
Page 76 and 77: GERMANY What major innovations and
Page 78 and 79: INDIA Private health insurance: The
Page 80 and 81: INDIA provide after-hour care, reim
Page 82 and 83: INDIA are provided by other ministr
Page 84 and 85: INDIA How are costs contained? Ther
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Page 88 and 89: ISRAEL Together, these two types of
Page 90 and 91: ISRAEL Primary care physicians are
Page 92 and 93: ISRAEL Organization of the Health S
Page 94 and 95: ISRAEL • Using electronic health
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Page 98 and 99: ITALY during hospitalization (Thoms
Page 100 and 101: ITALY Some regions are promoting ca
Page 102 and 103: ITALY Organization of the Health Sy
Page 104 and 105: ITALY although the degree of evolut
Page 106 and 107: ITALY The author would like to ackn
Page 108 and 109: JAPAN What is covered? Services: Al
Page 110 and 111: JAPAN incentives for providers to c
Page 114 and 115: JAPAN The author would like to ackn
Page 116 and 117: THE NETHERLANDS receive faster acce
Page 118 and 119: THE NETHERLANDS Hospital payment ra
Page 120 and 121: THE NETHERLANDS Organization of the
Page 122 and 123: THE NETHERLANDS References Organisa
Page 124 and 125: NEW ZEALAND provided in GP clinics.
Page 126 and 127: NEW ZEALAND management (e.g., clean
Page 128 and 129: NEW ZEALAND including such informat
Page 130 and 131: NEW ZEALAND largely through efficie
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Page 134 and 135: NORWAY Primary, preventive, and nur
Page 136 and 137: NORWAY Patients are free to choose
Page 138 and 139: NORWAY What are the major strategie
Page 140 and 141: NORWAY The National System for the
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Page 144 and 145: SINGAPORE Medifund is the governmen
Page 146 and 147: SINGAPORE Public hospital funding i
Page 148 and 149: SINGAPORE Public consultation: The
Page 150 and 151: SINGAPORE To keep demand for servic
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Page 154 and 155: SWEDEN What is covered? Services: T
Page 156 and 157: SWEDEN Hospitals: There are seven u
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SWITZERLAND Insurers offer premiums
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SWITZERLAND Hospitals: About 70 per
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SWITZERLAND Organization of the Hea
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SWITZERLAND To control pharmaceutic
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UNITED STATES What is covered? Serv
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UNITED STATES Administrative mechan
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UNITED STATES The Institute of Medi
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UNITED STATES adopted at least a ba
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The COMMONWEALTH FUND Affordable, q
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JANUARY

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